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26 June 2013 Nursing Management

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1.9
CONTACT HOURS

Targeting MRSA:
Is it the right infection
prevention goal?
Focus on universal infection prevention
strategies, instead of targeted approaches, to
reduce MRSA and other healthcare-associated
infections.
By Frank Edward Myers III, MA, CIC

ethicillin-resistant Staphylococcus aureus

(MRSA) is an important pathogen both inside
the hospital and within the community. Many
studies have shown that it increases morbidity and mortality when compared with its
less drug-resistant relativemethicillin-sensitive S. aureus.
The literature and guidelines are divided into two very
different approaches for the best use of healthcare resources
to minimize transmission of the organism. After years of
debate, a national consensus on best practices is building;
unfortunately, it appears to be at odds with many state
legislature mandates. The good news is that these universal infection prevention strategies, when followed, may
not only reduce MRSA transmission rates, but also the
spread of other healthcare-associated pathogens.

A history of resistance
Since the 1970s, cyclical increases in S. aureus infection
have been noted in communities and hospitals. During the
outbreak of S. aureus in North America in the 1950s and
1960s, it was firmly established as a healthcare-associated
pathogen. MRSA was first identified in 1961, 2 years after

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Nursing Management June 2013 27

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Targeting MRSA: Is it the right infection prevention goal?

methicillin was approved for treatment of S. aureus infection. MRSA

infection rates continued to increase
slowly but steadily in North America
through the 1970s and 1980s. Regional
variation in North America existed;

certain areas had much higher rates

of infection than others. By the late
1990s, MRSA infection reached epidemic proportions.
The MRSA epidemic of the late
1990s and early 2000s wasnt

Table 1: Contact precautions review

Issue

Action

Patient
room

In acute care hospitals, place patients who require contact

precautions in a single-patient room when available.
In long-term-care and other residential settings, make
decisions regarding patient placement on a case-by-case basis,
balancing infection risks to other patients in the room, the
presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the
infected or colonized patient.
In ambulatory settings, place patients who require contact
precautions in an examination room or cubicle as soon as
possible.

Gloves

Wear gloves whenever touching the patients intact skin or surfaces and articles in close proximity to the patient, such as
medical equipment or bed rails. Put on gloves upon entry into
the room or cubicle.

Gowns

Wear a gown whenever clothing will have direct contact with the
patient or potentially contaminated environmental surfaces or
equipment in close proximity to the patient. Put on a gown
upon entry into the room or cubicle. Remove gown and practice
hand hygiene before leaving the patient care environment.

Transport

In acute care hospitals and long-term-care and other residential

settings, limit transport and movement of patients outside of
the room to medically necessary purposes.
When transport or movement in any healthcare setting is
necessary, ensure that infected or colonized areas of the
patients body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene before
transporting patients on contact precautions.

Equipment

In acute care hospitals and long-term-care and other residential

settings, use disposable noncritical patient care equipment,
such as BP cuffs, or implement patient-dedicated use of such
equipment. If common use of equipment for multiple patients
is unavoidable, clean and disinfect such equipment before use
on another patient.
In home settings, limit the amount of nondisposable patient
care equipment brought into the home of patients on contact
precautions. Whenever possible, leave patient care equipment
in the home until discharge from home care services.
In ambulatory settings, place contaminated reusable noncritical patient care equipment in a plastic bag for transport to a
soiled utility area for reprocessing.

Cleaning
Ensure that the rooms of patients on contact precautions are
of the
prioritized for frequent cleaning and disinfection (at least daily),
environment with a focus on frequently touched surfaces (bed rails, overbed
table, bedside commode, lavatory surfaces in patient bathrooms,
doorknobs, and so on) and equipment in the immediate vicinity
of the patient.

28 June 2013 Nursing Management

driven by an increase in healthcare

transmission or sicker inpatients
getting infected, but by a strain of
MRSA that developed resistance
to treatmentoriginally called
community-associated MRSA. This
name was discontinued after it was
shown that, in some cases, the community strain and the healthcareassociated strain (albeit rarely) were
both being transmitted in the community.1 The new strain became
known as USA300. Despite headlines in the popular press, this
strain didnt escape from hospitals; it developed independently in
the community.2
The contact precautions conundrum
As press coverage of the outbreak
gained in prominence, the search for
answers became more pressing. There
was a broad consensus that contact
precautions for MRSA infections
were necessary. This approach is still
supported by the Healthcare Infection Control Practices Advisory
Committee (hicpac) guidelines,
commonly known as the CDC guidelines.3 Contact precautions allow for
a wide range of practice by facilities.
However, questions surrounding
the implementation of contact precautions still exist. This is, in part,
because contact precautions have
been associated with several negative
outcomes. (See Table 1.)
Some studies have demonstrated
that healthcare workers, including
attending physicians, are half as
likely to enter the rooms of (or
examine) patients on contact precautions.4-6 Studies have also
reported that patients in private
rooms and on barrier precautions
for a multidrug-resistant organism
(MDRO), including MRSA, have
increased anxiety and depression
scores.7 A number of patients in
other studies have reported significantly more preventable adverse
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events, greater dissatisfaction with

their treatment, and less documented care than control patients
who arent in isolation.8,9 Other negative outcomes of contact precautions include the cost of personal
protective equipment (PPE) and longer ED wait times.10 Its also been
noted in the literature that patients
on contact precautions have higher
acquisition rates of other MDROs.11
According to the hicpac guidelines, institutions are encouraged
to develop their own strategies for
MRSA colonized and/or infected
patients. Some institutions require
gowning and gloving for all staff
entering the room of a patient on
contact precautions for easier evaluation of staff adherence. Other
institutions require gowning only
when contact with the patient is
expected or only in certain areas of
the patients room. This approach
minimizes the costs of PPE. Ironically, in most cases, hand hygiene
doesnt appear to increase in contact
precaution rooms compared with
noncontact precautions rooms.12
Active surveillance testing
After this point of theoretical, if
not functional, agreement on the
use of contact precautions for
patients with MRSA, vigorous academic debate focused on other best
practices, such as active surveillance
testing (AST)the screening of
patients for MRSA on admittance,
usually via nasal cultures. Some
facilities targeted patients perceived
to be at highest risk for MRSA,
whereas others performed AST on
all patients entering the facility.
Through this method, additional
patients with MRSA colonization
can be identified and placed on contact precautions, which theoretically
reduces MRSA transmission.
The Netherlands and other Scandinavian countries adopted this
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search and destroy approach to

MRSA and had very low MRSA
infection rates compared with
nations that werent using AST.13
A study of AST use in a large
number of U.S. facilities was conducted and the results also indicated MRSA reduction.14 In 2003,
the Society for Healthcare Epidemiology of America (SHEA) issued
guidelines recommending AST for
detecting MRSA.13
Some facilities embraced AST as a
best practice; others pointed to deficiencies published in the literature,
noting that MRSA occurred more
often in settings where AST was
practiced. Still others discussed the
increased costs associated with the
additional testing. In 1 weeks time,
two contradictory articles on AST
were published in high-impact
medical journals.15,16 But the preponderance of data was slowly building
on one side of the argument.
In 2008, an article appeared in the
SHEA journal condemning AST as a
flawed infection control response.17
The authors noted that focusing on a
single organism (MRSA) prevented
far fewer healthcare-associated
infections (HAIs) than did broader
infection prevention approaches.
The article discussed targeted
approaches (AST for MRSA) versus
universal approaches (such as central line insertion practice checklists) that impacted all infections
related to a device or procedure.
For example, reducing central lineassociated bloodstream infections
(clabsis) by 12.5% is the equivalent
of reducing MRSA infections by
50%. A 25% reduction in clabsis
would be equivalent to eliminating all
MRSA infections. This populationbased argument suggested that a
new, broader approach was needed
to handle MRSA as one of a number
of pathogens rather than as an independent problem causing HAIs.

One of many
At the same time, MRSAs role as
the major healthcare-associated
pathogen was being reexamined. In
2009, an article was published in
JAMA showing that, contrary to
public perception, MRSA had been
in decline as a cause of clabsis
since 2001.18 This was 2 years before
any professional society suggested
AST and around the same time that
the CDC published its hand
hygiene guidelines that supported
the use of alcohol-based hand sanitizers in healthcare, a much broader
approach to controlling HAIs.
Recent data suggest that MRSA
infections are becoming even rarer;
a CDC analysis reported that invasive MRSA infections in the United
States have dropped from an estimated 111,000 cases in 2005 to
82,000 in 2010.19
Recently, a three-armed study
demonstrated the superiority of a
universal approach to infection prevention by reducing all infections,
including MRSA. The REDUCE
MRSA Trial was conducted on 74
adult ICUs in 43 hospitals. In this
study, participants were assigned
to one of three arms.20 Arm one
included AST followed by contact
precautions if the patients screening
was positive for MRSA. Arm two
was AST followed by contact precautions if the patients screening
was positive for MRSA, decolonization with mupirocin in the nose,
and chlorhexidine gluconate (CHG)
baths using a CHG cloth for 5 days.
Arm three had no AST but every
patient was given the decolonization regimen of mupirocin in the
nose and daily CHG baths for the
duration of their stay. Arm three
showed a greater reduction in ICUattributed MRSA clinical cultures
and an overall reduction in ICUattributed clabsis than the other
two arms.

Nursing Management June 2013 29

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Targeting MRSA: Is it the right infection prevention goal?

This information, combined with

the increasing prevalence of Clostridium difficile and multidrugresistant Gram-negative rods,
reveals that best practice should
include a push toward a universal
infection control approach for
dealing with all HAIs.
Universal infection prevention
Universal approaches that are best
supported by the current literature
can be broken into five groupings:
bundles
environmental cleaning
patient hygiene
healthcare worker hand hygiene
antimicrobial stewardship.

Bundles
Bundles have gained visibility in
the last few years. A bundle is
an approach of implementing a
number of interventions aimed at
reducing a problem, such as reducing clabsis. These bundles can be
introduced in a fashion that will
allow a practitioner to create a
checklist so that he or she may
check off his or her compliance
with these interventions and permit others to validate compliance
with the intervention, allowing
for both process (compliance with
bundle) and outcome measures
(infections).
Now that the Centers for Medicare and Medicaid Services links
reimbursement to bundles, such as
the Surgical Care Improvement
Project and central line insertion
bundle, most institutions are very
familiar with these approaches.
Some institutions, however, are less
familiar with the bundle designed
to reduce catheter-associated urinary tract infections. This bundle
focuses on removing unnecessary
catheters, performing routine perioperative care, securing the catheter, maintaining a closed system,

and keeping the bag off the floor

and below the patients bladder.21
Other bundles have been developed
to reduce late onset clabsis (catheter maintenance bundles) by focusing on removing the line as soon as
possible (usually by verifying daily
line necessity), scrubbing the hub
before accessing a line, covering
the site with a dressing, and changing the dressing every 7 days or as
needed.
Complying with the ventilatorassociated pneumonia (VAP) bundle is another way to reduce MRSA
and other HAIs. The VAP bundle
focuses on removing the patient
from the ventilator as soon as possible (usually by encouraging daily
assessment for readiness to extubate), reducing sedation for a period
during the day, elevating the head
of the bed between 30 degrees and
45 degrees, and performing daily
CHG oral care. It should be noted
that one area of the original Institute
for Healthcare Improvement VAP
bundle, which uses H2 blockers
and proton pump inhibitors to prevent peptic ulcer disease, is controversial because it may increase the
likelihood of the patient developing
C. difficile.22

given us the ability to see if items

have been wiped with sufficient
friction to remove bioburden.
When this technology is used,
environmental cleaning markedly
improves.25 It has also been shown
to be an effective teaching method
for environmental service staff
learning how and what to clean. Its
widely thought that this technology
should also be used for training and
evaluating nursing staff members
because theyre frequently assigned
cleaning responsibilities for patientcare equipment. In addition, clear
roles about who cleans what on a
patient-care unit need to be defined
and reviewed with all staff on a
regular basis.
Although novel technologies,
such as UV light and hydrogen
peroxide plasma, have shown some
promise in preventing MRSA and
other HAIs, they still require a staff
member to preclean a room. Additionally, the data arent definitive
regarding effectiveness, revealing
that some technologies pose safety
challenges and delays in room turnaround, which prolongs patients
stay in EDs where inappropriate
cleaning and hand hygiene challenges are significant.

Environmental cleaning

Patient hygiene

Occupying a room that previously

housed a patient with MRSA or
another MDRO is a known risk
factor for acquiring that bacteria.23
Recently, studies have shown that
rooms are cleaned much less than
previously thought; one study
noted that at over 40 hospitals, less
than half of the high-touch surfaces
in a patients room were cleaned.24
The authors also discovered that,
until recently, we had no way of
knowing whether something was
actually clean.
The use of novel technology, such
as luminescent gel or powder, has

Patient hygiene is becoming an

increasing focus for preventing the
transmission of MRSA and other
HAIs. The data to date have focused
primarily, but not exclusively, on
patients in the ICU and the use of
CHG. As shown in the REDUCE
MRSA Trial, MRSA and other HAI
rates can decrease significantly
when the patient is bathed daily.
However, it should be noted that
there are disparities in the literature; some studies have shown that
CHG with bath basins fails to
reduce MRSA, whereas others have
shown success with CHG.26,27

30 June 2013 Nursing Management

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Nevertheless, given the repeated

studies in different acute care settings demonstrating reduction in at
least some HAIs (MRSA, C. difficile,
clabsis, surgical site infections, and
vancomycin-resistant enterococci)
with CHG use and the marginal
adverse reactions of such an approach,
theres little rationale for not implementing it.

Healthcare worker hand hygiene

Hand hygiene has been recognized
as an important step toward interrupting disease transmission. Studies have also been conducted that
show increasing hand hygiene has
reduced MRSA transmission on a
unit.28,29 Unfortunately, very little
data have been produced that
demonstrate the ability to gain
and maintain 100% hand hygiene
adherence.
However, in the past few years,
new technologies have been developed that allow for reminders and
evaluation of healthcare worker
hand hygiene at specific times,
such as upon entering and exiting
a patients room. These products,
although not infallible, allow unbiased and constant evaluation of
units or, in some cases, specific
healthcare worker hand hygiene
adherence. This technology is
promising but hasnt yet gained
wide usage in acute care settings.

Antimicrobial stewardship
Antimicrobial stewardship has
been noted to be an effective way
to control MRSA and other
MDROs.30 Antimicrobial stewardship is a set of coordinated
strategies to improve the use of
antimicrobial medications with the
goal of enhancing patient health
outcomes, reducing resistance to
antibiotics, and decreasing unnecessary costs.31 In fact, the early
literature supporting AST for
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reducing MRSA at one institution

was mirrored by claims that antibiotic controls had also reduced
MRSA at the same institution. Currently, The Joint Commission and
several states are requiring that
antibiotic stewardship be conducted
by all healthcare institutions.
However, this approach is ill
defined at this time and institutions
with few resources, such as infectious disease pharmacists and/or
infectious disease physicians, are
less likely to implement this intervention than institutions that are
considered resource rich. Nurses
prompting physicians to be aware
of negative culture results or
responding to sensitivities can
reduce inappropriate antibiotic
or broad-spectrum antibiotic use,
thus helping to reduce MRSA and
other HAIs.
This way to best practices
MRSA is still a very important and
dangerous hospital pathogen. The
best practice for reducing MRSA is
to take approaches that will reduce
other healthcare-associated pathogens, not solely focusing on MRSAspecific interventions. NM
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Nursing Management June 2013 31

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Targeting MRSA: Is it the right infection prevention goal?

known as proton pump inhibitors (PPIs).
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Frank Edward Myers III is an infection preventionist III at U.C. San Diego (Calif.) Health
System and an editorial board member of
Nursing2013.
The author and planners have disclosed that
they have no financial relationships related to
this article.
DOI-10.1097/01.NUMA.0000430402.57959.15

For more than 147 additional continuing education articles related

to management topics, go to NursingCenter.com/CE.

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22. FDA. FDA dug safety communication:
Clostridium difficile-associated diarrhea
can be associated with stomach acid drugs

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